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BASIC CONCEPTS

A communication deficit is an impairment in the abil- ity to receive, send, process, and comprehend concepts or verbal, nonverbal, and graphic symbol systems, as defined by the American Speech-Language-Hearing Association (ASLHA, 1993).In 2001, the World Health Organization (WHO)'s International Classification of Functioning, Disabil- ity and Health shifted away from a medical diagnosis model to a functional model (i.e., how the person with a sensory impairment functions in his or her everyday life).The degree of difficulty in com- municating is an interaction between the client's type of functional impairment, personal adaptability, and the health care environment (i.e., body factors, per- sonal factors, and environmental factors as stated in WHO's model).Communication deficits can also arise from the kind of sensory depri- vation that occurs in some agencies and units, such as intensive care units.Even when care is accessed, com- munication deficits interfere with the therapeutic rela- tionship and delivery of optimum care (Markov and Hazan, 2012).GOAL

Our primary nursing goal is to maximize our client's ability to successfully communicate and to interact with the health care system to ensure optimal health and quality of life.Severe cognitive and sensory deficits interfere with communication, decrease access to health care, and lead to feelings of frustration.Under this model, a communication disability definition includes any client who has any impairment in body structure or function that interferes with com- munication.Specifically, the client has a communica- tion difficulty because of impaired functioning of one or more of the five senses, or the client has impaired cognitive processing functioning.Two individuals can have the same sensory impairment but not be equally commu- nication disabled.These include deficits such as compromised hearing, vision, speech, language, or problems with cognitive processing (O'Halloran et al., 2012).Evidence shows us that when nurses are unable to understand them, clients with commu- nication disabilities become frustrated, angry, anxious, depressed, or uncertain.Many of these individ- uals report delays or difficulties obtaining health care.When working with these clients, you may need to modify communication strategies presented earlier in this textbook.Some clients become so frus- trated that they exhibit behavioral problems or even omit needed care.They may be congenital or acquired; they range from mild to severe.But other barriers may include staff's negative attitude or inability to adapt communication.Over- all, nearly one in six Americans has a sensory or com- munication deficit, which is nearly 50 million people (U.S. Department of Health and Human Services, n.d.).Assess every client's communication abilities.Improving access to care for these clients is one of the goals of Healthy People 2020.Any impairment of a client's ability to send and/ or receive information from health care providers may compromise his or her health, health care, and rights to make decisions.Each person compensates for his or her impairment in different ways.The client's deficit is one barrier.

BASIC CONCEPTS

A communication deficit is an impairment in the abil- ity to receive, send, process, and comprehend concepts or verbal, nonverbal, and graphic symbol systems, as defined by the American Speech-Language-Hearing Association (ASLHA, 1993). These include deficits such as compromised hearing, vision, speech, language, or problems with cognitive processing (O'Halloran et al., 2012). They may be congenital or acquired; they range from mild to severe. Severe cognitive and sensory deficits interfere with communication, decrease access to health care, and lead to feelings of frustration. Over- all, nearly one in six Americans has a sensory or com- munication deficit, which is nearly 50 million people (U.S. Department of Health and Human Services, n.d.). Improving access to care for these clients is one of the goals of Healthy People 2020. Many of these individ- uals report delays or difficulties obtaining health care.

In 2001, the World Health Organization (WHO)'s International Classification of Functioning, Disabil- ity and Health shifted away from a medical diagnosis model to a functional model (i.e., how the person with a sensory impairment functions in his or her everyday life). Under this model, a communication disability definition includes any client who has any impairment in body structure or function that interferes with com- munication. Specifically, the client has a communica- tion difficulty because of impaired functioning of one or more of the five senses, or the client has impaired cognitive processing functioning. Communication deficits can also arise from the kind of sensory depri- vation that occurs in some agencies and units, such as intensive care units. The degree of difficulty in com- municating is an interaction between the client's type of functional impairment, personal adaptability, and the health care environment (i.e., body factors, per- sonal factors, and environmental factors as stated in WHO's model).

Any impairment of a client's ability to send and/ or receive information from health care providers may compromise his or her health, health care, and rights to make decisions. When working with these clients, you may need to modify communication strategies presented earlier in this textbook. Assess every client's communication abilities. Two individuals can have the same sensory impairment but not be equally commu- nication disabled. Each person compensates for his or her impairment in different ways.

GOAL

Our primary nursing goal is to maximize our client's ability to successfully communicate and to interact with the health care system to ensure optimal health and quality of life. Evidence shows us that when nurses are unable to understand them, clients with commu- nication disabilities become frustrated, angry, anxious, depressed, or uncertain. Some clients become so frus- trated that they exhibit behavioral problems or even omit needed care. Even when care is accessed, com- munication deficits interfere with the therapeutic rela- tionship and delivery of optimum care (Markov and Hazan, 2012). The client's deficit is one barrier. But other barriers may include staff's negative attitude or inability to adapt communication.

LEGAL MANDATES

In the legal system, the standard of "effective commu- nication" is based on several statutes. The Americans with Disabilities Act (ADA) prohibits discrimination on the basis of a disability. Thus physician offices are required to provide reasonable accommodations to ensure effective communication. The Rehabilitation Act bars discrimination by those providers receiving federal monies, including Medicare. Title VI of the 1964 Civil Rights Act prohibits discrimination on the basis of national origin.

HOME-BASED HEALTH CARE

Visiting clients with communication deficits in their home allows nurses the time to engage in collaborative negotiations for which there may not have been time during acute care management. Home health nurses can build the infrastructure needed to prevent worsen- ing of disability, as demonstrated in a study of elders by Liebel and associates (2012).

TYPES OF DEFICITS

HEARING LOSS

More than 28 million Americans have some prob- lem hearing. Loss can be conductive, sensorineural, or functional. Causes can be genetic or acquired, such as due to infections, medication toxicity, or even due to exposure to excessive noise, such as occurs in com- bat. Hearing losses, especially in higher ranges, are most often found in older aged clients.Nurses have both a legal and ethical obli- gation to provide appropriate care. Yet, deaf people are less likely to seek health-related information from care providers. Title III of the ADA delineates rights of the deaf and applies to communication between deaf clients and medical services.

People's sense of hearing alerts them to changes in the environment so they can respond effectively. The listener hears sounds and words, and also a speak- er's vocal pitch, loudness, and intricate inflections accompanying the verbalization. Subtle variations can completely change the sense of the communication. Combined with the sound and intensity, the organiza- tion of the verbal symbols allows the client to perceive and interpret the meaning of the sender's message. The extent of your client's loss is not always appreciated because they often look and act in a normal fashion. Even mild to moderate hearing losses can lead to sig- nificant functional impairments (George et al., 2012). Deprived of a primary means of receiving signals from the environment, clients with hearing loss may try to hide deficits, may withdraw from relationships, become depressed, or be less likely to seek information from health care providers.

Children. Nearly 3 of every 1000 newborns are deaf or have hearing loss (U.S. Department of Health and Human Services, n.d.). Fortunately, many of these deficits are diagnosed at birth. Newborn hearing is tested in the nursery via auditory brainstem response tests (see the National Institute on Deafness and Other Communication Disorders web site at www.nidcd.nih.gov). Hearing screening is recommended for all newborn children by the U.S. Preventive Services Task Force (USPSTF) (AHRQ, 2012) and American Academy of Pediatrics.

Older Adults. As we age, we have an increased likelihood for presbycusis, or degeneration of ear structures, which is a sensorineural dysfunction that normally occurs with aging.

VISION LOSS

Humans rely more heavily on vision than do most spe- cies. Nearly 5 million Americans are blind or have uncor- rectable visual impairments (National Eye Institute, n.d.). The majority of these are older than 50 years of age. Clients who lack vision lose a primary method to decode the meaning of messages. All of the nonver- bal cues that accompany speech communication (e.g., facial expression, nodding, and leaning toward the

client) are lost to blind clients. Even with partial loss, it is important for you to assess whether your client can read directions, medication labels, and so forth. Children. Children with visual impairments lack access to visual cues, such as the facial expressions that encourage them to develop communication skills. The USPSTF recommends testing children younger than 5 years for amblyopia, strabismus, and acuity, but traditional vision screening requires a verbal child and cannot be done reliably until age 3 years.

Older Adults. As we age, the lens of the eye becomes less flexible, making it difficult to accommodate shifts from far to near vision; this is a condition known as presbyopia. Macular degeneration has also become a major cause of vision loss in older adults.